What is concordance?
Marjorie Weiss and Nicky
Britten explain what concordance is and what it is not
Marjorie Weiss is senior lecturer at the University of Bath school
of pharmacy and Nicky Britten is professor of allied health care
research at the Peninsula Medical School, Exeter
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Concordance seems to mean different things to different people. For
some, it is merely the latest in a series of terms used to describe compliance
and, more recently, adherence. For others, it is a radical shift in
the
way we think about how patients take medicines. Our aim is to describe
what we think concordance is about, how it differs from previous ways
of thinking about medicine-taking, and the implications for health
care professionals.
Concordance is fundamentally different from either compliance or adherence
in two important areas: it focuses on the consultation process rather
than on a specific patient behaviour, and it has an underlying ethos
of a shared approach to decision-making rather than paternalism.
Concordance refers to a consultation process between a health care
professional and a patient. Compliance refers to a specific patient
behaviour: did
the patient take the medicine in accordance with the wishes of the
health care professional? For this reason it is possible to have a
non-compliant
(or non-adherent) patient. It is not possible to have a non-concordant
patient. Only a consultation or a discussion between the two parties
concerned can be non-concordant.
Sharing of power
Crucially, concordance advocates a sharing of power in the professional-patient
interaction. Concordance values the patient’s perspective, acknowledging
that the patient has expertise in his or her body’s experience
of illness and response to treatment. This expertise is different from
the professional’s scientific expertise in drug treatment selection
but is of equal relevance and value in terms of deciding on best management.
A concordant consultation is one that includes both these views in
the decision-making process regarding management. This is contrasted
with the paternalistic approach underlying compliance: the patient
is assumed to take an essentially passive role in the consultation
and to be obedient to the health care professional’s advice.
Paternalism is still possible in concordance provided it reflects the
patient’s preference for involvement in the decision-making process
and that this preference has been actively elicited in the consultation.
Health care professionals sometimes assume a patient wants a paternalistic
approach — that they should make the decision on how best to
treat them. However, research suggests that professionals are often
unable accurately to “guess” a patient’s preferred
role in decision making.1 It would seem that the best way to find out
if patients want to be involved in decision making is to ask them.
Why do we need concordance? Put simply, the older models of adherence
have had only a limited effect on patient medicine-taking behaviour.
A recent review of adherence2 concluded that the full benefits of medication
cannot be realised at currently achievable levels of adherence, underlining
the inadequacies of the paternalistic approach for ensuring the best
use of medicines.3 Will concordance ensure a more effective use of medicines — less
drug wastage and fewer hospital admissions due to the iatrogenic effects
of drugs? We do not know — the impact of concordance on patient
outcomes is still unknown. Definitive evidence is difficult to ascertain
as the concordance “package”, including its several constituent
parts (eg, exploring patient medication concerns, working together with
patients to develop a treatment regimen), has rarely been evaluated comprehensively.
Most of the evidence to date concerns an evaluation of one or more elements
of concordance or the evaluation of an approach allied to concordance,
such as “patient-centredness” or “shared decision-making”.
Nonetheless, a recent systematic review of the literature relevant to
concordance
found that two-way communication between patients and professionals about
medicines led to improved satisfaction with care, knowledge of the condition
and treatment, adherence, health outcomes and fewer medication-related
problems.4
Not all health care professionals will welcome concordance; some will
have reservations about giving the patient’s view primacy. It is
possible for patients to reject what may be considered (by the professional)
to be best clinical practice even when they have been fully informed
as to the nature and consequences of this decision. In these situations,
concordance does not detract from the autonomy of the health care professional
to document such events fully or refuse to supply or prescribe a medicine
in situations considered to be pharmaceutically unsafe. Even so, health
care professionals may believe they are at risk of litigation should
a patient who has refused best treatment suffer an adverse event as a
result. However, research evidence suggests this is unlikely. Levinson
et al conducted a study among physicians who had a history of previous
malpractice claims and those with no previous malpractice history. They
found that physicians with no previous history of malpractice claims
had better communication consultation skills, using more facilitative
talk such as soliciting the patient’s opinion and encouraging them
to talk.5 In this context, concordance is about raising to a level of
explicitness those decision making processes, by both the patient and
health care professional, which were previously unelaborated or occurred
outwith the consultation.3
Another major concern for health care professionals is time. Will discussion
of patients’ views give rise to long consultations that would be
impractical in primary care? There is some evidence that discussion of
patients’ views does not necessarily lead to longer consultations6 and may in any
case save time in the longer term through resolution of misunderstandings.
Other researchers suggest that using such an approach will take longer
initially but this will settle and reduce as a professional gets more
proficient in this approach.7 Time is an important issue given the current
structural limitations of the primary care practice setting. However
it should not be used as an excuse for not trying out concordance.
A shift in thinking
Concordance is a shift in how we think about medicine-taking. It challenges
us to find out the real concerns patients have about taking medicines
and into working with patients to discover imaginative solutions on
how they can make best use of their medicines. Is it not worth a try?
References
1. Strull WM, Lo B, Charles G. Do patients
want to participate in medical decision making? JAMA 1984;
252:2990–4.
2. Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC,
Kanani R. Interventions for helping patients to follow prescriptions
for
medications (Cochrane review). In: The Cochrane Library, Issue 1,
Update Software, Oxford. 2001.
3. Britten N, Weiss MC. What is concordance? In: Bond C (editor).
A concordance reader. London: The Pharmaceutical Press. In press.
4. Cox K, Stevenson F, Britten N, Dundar Y. A systematic review of
communication between patients and health care professionals about
medicine-taking and prescribing. London: GKT Concordance Unit, King’s
College; 2003.
5. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient
communication — the relationship with malpractice claims among
primary care physicians and surgeons. JAMA 1997;277:553–9.
6. Belle Brown J. Time and the consultation. In: Jones R et al (editors).
Oxford textbook of primary medical care. Oxford: Oxford University
Press. In press.
7. Stewart M, Belle Brown J, Weston WW. Patient-centred interviewing
Part III: five provocative questions. Can Fam Physician 1989;35:159–61. |
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